I am over the age of 18 and desire Mileide Marques, Monique Marques, AAdditional Signature Boxlessandra Muller or Heather Petty-Harris to perform the elective cosmetic pigmentation procedure understanding that this procedure is for cosmetic purposes only and not for health reasons. If any unforeseen conditions arise in the course of this procedure calling for his/her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize him/her to do whatever necessary in the circumstances. I am aware that no guarantees have been made to me concerning the results of the procedure(s). Date: September 29, 2022
I also understand that the permanent skin pigmentation procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes risk of infection, scarring, eye damage, inconsistent color, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any products used. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. Laser treatments may also compromise the permanent cosmetic make-up application. I fully understand as with all such procedures that this is not a science but rather an art and that anything that can go wrong may go wrong. I request the permanent skin pigmentation procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences of the said procedure(s). Date: September 29, 2022
For the purpose of documentation, I also consent to the taking of before, during and after photographs / videos of said procedure(s) which become the technician's sole property and may or may not be used for what ever purpose deemed necessary including using pictures for social media and advertising publications. IF YOU DO NOT WANT YOUR PICTURES POSTED ONLINE PLEASE ADVISE YOUR TECHNICIAN SHE WILL MARK YOUR SKIN WITH AN (X) PRIOR TO TAKING PHOTOS. Understanding the permanent skin pigmentation procedure, the procedure, the permanency of the procedure, the possible consequences of the procedure, and that the procedure is for cosmetic purposes only, I hereby authorize Mileide Marques, Monique Marques, Alessandra Muller, Grace OR Heather Petty-Harris to perform the permanent skin pigmentation procedure(s). Please sign Yes or No. Date: September 29, 2022
I understand Microblading and any elective permanent make up is considered a tattoo in the State of Georgia and I will not be able to donate blood for one year. Please check state laws before donating blood. Date: September 29, 2022
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.